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Monster Moms 2 Hygiene & Food Pantry Application
1357 Rice rd, San Antonio,Tx 78220
For (MONSTER MOMS)Internal Use Only
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Date
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Month
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Day
Year
Name
*
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
04191970
Email
*
example@jtmolina@gmail>comexample.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you impacted by
Homelessness
Justice
Domestic Violence
Trauma
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service(s) Requesting (Food Bank)
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How many individuals in your family ?
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Name, DOB, and Age of anyone (outside of yourself) in the household {need to match house size or you will get the amount of food the size below displays.
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First Name /Last Name molina bella
Address/household size
Name
*
First Name /Las t Name
Address/household size
Name
*
First Name /Last Name
Address/household size
Name
*
First Name /Last Name
Address/household size
Name
First Name /Last Name
Address/household size
Name
First Name /Last Name taty molina
Address/household size
Proxy
First Name /Last Name
Phone
TEFAP Is anyone in your household currently receiving SNAP or Food stamps ?
*
TEFAP Is anyone in your household currently receiving SNAP or Food stamps ?
*
Yes
Don’t know/Prefer not to ask
Additional TEFAP ELIGIBILITY
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WIC
Unemployment
Don’t know/Prefer not to ask
Income (Weekly Amount)(choose one or the other)
*
Monthly Amount
*
Yearly
*
Is this household in a crisis?
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Please explain the household crisis you are experiencing?
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Disability Status: Does anyone in your household, including yourself, have a disability that prevents them from accepting any kind of work during the next six months?
*
Military Status: Has anyone in your household, including yourself, served on active duty in the U.S. Armed Forces?Active duty includes serving in the U.S. Armed Forces as well as activation from the Reserves or National Guard.
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Yes, on active duty in the past, but not now
Yes, now on active duty
No, never on active duty except for initial/basic training
Don't know / Prefer not to answer
Food Insecurity
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Often true
Sometimes True
Never true
"Within the past 30 days we worried whether our food would run out before we got money to buy more."
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Often true
Sometimes True
Never true
"Within the past 30 days the food we bought just didn't last and we didn't have money to get more."
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Often true
Sometimes True
Never true
Additional Household Members (first & last name , Date of birth
Additional Household Members (first & last name , Date of birth
Additional Proxy (1st name , last name phone )
Do you get food stamps, Medicaid or SSI or Lunch program? Which one are you eligible for? no
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I certify that: 1) I am a member or a proxy of the household living at the address provided and that, on behalf of the household, I apply for USDA Foods that are distributed through The Emergency Food Assistance Program; 2) all information provided to the agency determining my household's eligibility is, to the best of my knowledge and belief, true and correct. I acknowledge that I may be prosecuted for making false statements related to the information I have provided for this application.
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STAFF USE ONLY:Based on the information given above and the requirements for TEFAP, the neighbor appears to be:EligibleNo eligible
Race & Ethnicity: What race and/or ethnicity do you identify as? Select all that apply.
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Black or African American
Hispanic
White
Pacific Island
Asian
Other
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g. Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling,(866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: (1) mail: U.S. Department of Agriculture; Office of the Assistant Secretary for Civil Rights; 1400 Independence Avenue, SW; Washington, D.C. 20250-9410; or (2) fax: (833) 256-1665 or (202)690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.
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Demographics
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Female
Don't Know / Prefer not to answer
None of these
Employment Status: In the last month, did you or anyone in your household work for pay full-time (for 30 hours per week or more)?
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Yes
Don't Know / Prefer not to answer
I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for assistance.
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Submit
Should be Empty: